On the eve of World Breastfeeding Week 2018, I’m reminded of the tale of The Emperor’s New Clothes:

…about two weavers who promise an emperor a new suit of clothes that they say is invisible to those who are unfit for their positions, stupid, or incompetent – while in reality, they make no clothes at all, making everyone believe the clothes are invisible to them. When the emperor parades before his subjects in his new “clothes”, no one dares to say that they do not see any suit of clothes on him for fear that they will be seen as stupid. Finally, a child cries out, “But he isn’t wearing anything at all!”

Sadly, the story of lactivism is similar: professionals promise women that breastfeeding is a better way to feed their babies, provides massive benefits, and has no risks. They tell women that anyone who questions those benefits is stupid or incompetent, while in reality, the benefits of breastfeeding are trivial and the risks — of dehydration, hypoglycemia and jaundice — are significant. This has been going on for nearly three decades and there’s no evidence that increased breastfeeding rates have any impact on mortality, morbidity or healthcare savings for term infants. Breastmilk does reduce the risk of death from necrotizing enterocolitis in extremely premature infants, an exception that serves to prove the rule.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Everyone knows that breastfeeding has massive benefits, just as everyone knew that the sun revolved around the earth.[/pullquote]

It’s time to cry out the obvious: breastfeeding DOESN’T matter!

Why do we keep pretending it does? For the same reason that the emperor’s subjects were afraid to tell him he was naked: peer pressure. No one dares accept the evidence of their own eyes for fear of a powerful backlash.

In the case of the emperor, his subjects feared that he would punish them for insulting his dignity. In the case of breastfeeding, everyone is afraid they will be demonized by lactation consultants and their medical allies. Why? Because lactation professionals, whose dignity is apparently insulted by the truth that the promised benefits of breastfeeding have never appeared, react by vilifing, slandering and shunning.

Everyone “knows” that breastfeeding has massive benefits, just as everyone once “knew” that the sun revolved around the Earth. That wasn’t true, either, but there were religious leaders with a vested interest in promoting the biblical view of the solar system; because they had access to the levers of power, they were able to suppress the truth for generations. It was more important to religious leaders to maintain their belief system regardless of what the evidence showed. Anyone who opposed them faced draconian penalties.

The situation is not as bad for breastfeeding. A doctor like myself who dares point out the obvious does not face a trial and potential execution for heresy, just withering criticism. It is babies and mothers who suffer because those who hold the levers of power in the world of public health have a vested interest in suppressing the truth. It is more important to lactation professionals to maintain their belief system regardless of what the evidence shows and regardless of how many babies and mothers are hurt in the process.

It would be pathetically easy to prove me wrong if I were wrong:

Just show me how the infant mortality rate has dropped as breastfeeding rates have risen.

Just show me how the rate of serious medical illness has dropped as breastfeeding rates have rise.

Just show me how the rate of healthcare spending on infants has dropped as breastfeeding rates have risen.

Wait, what? No one can demonstrate even one of those things, let alone all three of them?

Of course not, because the emperor has no clothes.

No amount of pretending by his subjects could change the fact that the emperor was naked. Similarly no amount of pretending by lactation professionals changes the fact that breastfeeding doesn’t matter for term infants.

I will continue to point that out; vilification, slander and shunning won’t stop me. The only thing that will convince me otherwise is if someone demonstrates that breastfeeding has an impact on term infants in the real world, not just in the unvalidated theoretical models beloved of lactivists.

I’m not holding my breath.

The mainstream media is filled with stories claiming that the US maternal death rate has risen dramatically since 1990. The latest effort comes from USA Today, Hospitals know how to protect mothers. They just aren’t doing it.

The vast majority of women in America give birth without incident. But each year, more than 50,000 are severely injured. About 700 mothers die. The best estimates say that half of these deaths could be prevented and half the injuries reduced or eliminated with better care.

Instead, the U.S. continues to watch other countries improve as it falls behind. Today, this is the most dangerous place in the developed world to give birth.

They include a helpful chart:

There’s just one problem and it’s a big one: no one knows if those measurements of US maternal mortality are accurate. Indeed, there’s a growing body of evidence that the US is over-counting maternal deaths.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]There’s a growing body of evidence that the US is over-counting maternal deaths.[/pullquote]

In the 1990’s it was recognized that the US was failing to capture all maternal deaths. As a result, the US death certificate was changed twice (1999 and 2003) to add specific questions to determine the pregnancy status of the deceased. But death certificates are prepared by individual states and each changed their deaths certificates at different times.

As MacDorman et al. explained in 2016 in Is the United States Maternal Mortality Rate Increasing? Disentangling trends from measurement issues:

To improve ascertainment, a pregnancy question was added to the 2003 revision of the U.S. standard death certificate. The question has several checkboxes to ascertain whether female decedents were: Not pregnant within past year; pregnant at time of death; not pregnant, but pregnant within 42 days of death; not pregnant, but pregnant 43 days to 1 year before death; or unknown if pregnant within the past year…

However, there were delays in states’ adoption of the revised death certificate, and thus the new pregnancy question. In addition, some states had pregnancy questions that were inconsistent with the U.S. standard. This created a situation where, in any given data year, some states were using the U.S. standard question, others were using questions incompatible with the U.S. standard, and still others had no pregnancy question on their death certificates.

Due in part to the difficulties in disentangling these effects, the United States has not published an official maternal mortality rate since 2007 …

MacDorman et al. used statistical estimates to correct for the differences. While raw data suggested that US maternal mortality had more than doubled since 2000, they found that the real increase was only 26.4%, a much smaller increase, but an increase nonetheless.

But even this increase may not be real. Suspicion initially fell on the data from Texas that had shown a massive increase in maternal mortality:

Reproductive rights advocates seized on the data to argue that Texas’ efforts to roll back access to reproductive care had led to the increase, but a closer look revealed that the state had dramatically over-counted maternal deaths.

In Identifying Maternal Deaths in Texas Using an Enhanced Method, 2012, Baeva et al. found:

Fifty-six maternal deaths were confirmed to have occurred during pregnancy or within 42 days postpartum. Using our enhanced method, the 2012 maternal mortality ratio for Texas was 14.6 maternal deaths per 100,000 live births, less than half that obtained using the standard method (n5147). Approximately half (50.3%) of obstetric-coded deaths showed no evidence of pregnancy within 42 days, and a large majority of these incorrectly indicated pregnancy at the time of death.

How did this happen?

In Texas, unintentional user error in reporting pregnancy status may be responsible. Texas’ current electronic death registration system displays pregnancy status options as a dropdown list. The “pregnant at the time of death” option is directly below the “not pregnant within the past year” option; this could have led to erroneous selection and could explain why pregnancy at the time of death was reported for nearly 76% (n556) of the 74 obstetric-coded deaths with no evidence of pregnancy on review.

The situation in Texas is not unique.

MacDorman and Declercq writing in the June 2018 issue of Birth: Issues in Perinatal Care (published on behalf of Lamaze International) note:

For example, a recent Centers for Disease Control and Prevention (CDC) report from maternal mortality review committees in four states found that 15% (97/650) of reported maternal deaths were not maternal deaths at all, since the women involved were confirmed to be not pregnant or postpartum within 1 year of death. The same study also found that the checkbox identified cases, particularly during pregnancy or late postpartum, that were identified only because of the checkbox, and with no other evidence that the case was a maternal death. Thus, the errors of overcounting were predominantly because of errors in the pregnancy checkbox.

This is a serious error:

The problems in reporting of pregnancy status are compounded by United States coding rules that code every death with the pregnancy or postpartum checkbox checked to maternal causes, regardless of what is written in the cause-of-death section. The only exception is for external causes of injury (ie, accident, suicide, or homicide) which are coded to non-maternal causes. This coding scheme makes the checkbox information essentially the sole factor in deciding whether a death is maternal or nonmaternal. For example, right now, if “sunburn” is written as the cause of death, and if the pregnancy or postpartum checkbox is checked, United States coding rules code this as a maternal death. This coding is clearly not in keeping with the spirit of the World Health Organization maternal mortality definition of maternal death …

They conclude:

Given concerns about overreporting with the pregnancy checkbox, it is illogical to continue to use it as the sole means of identifying maternal deaths. The National Center for Health Statistics (the agency responsible for collecting and disseminating NVSS data) should undertake a systematic evaluation of current coding methods for maternal deaths, and develop scientifically defensible alternative methods, which are compatible with international standards.

There a scientific aphorism that suggests extraordinary claims require extraordinary evidence. In this case there are two extraordinary claims: since 1999 US maternal mortality has risen dramatically and the US now has the highest maternal mortality in the industrialized world.

The evidence, far from being extraordinary, is incredibly inaccurate because of over-counting.

That does NOT mean that our efforts to reduce maternal mortality should flag. No one is questioning the massive gap in maternal outcomes between black and white women and that must be reduced. But it does mean that the hand wringing over the rise in US maternal mortality might be both premature and overblown.

Aaron Carroll had a fabulous piece in yesterday’s New York Times entitled What if a Study Showed Opioids Weren’t Usually Needed?

Participants were randomly assigned to one of two arms. Both involved stepwise progression from less to more potent medications. One arm involved opioid medications (a progression from hydrocodone/acetaminophen to sustained release morphine to fentanyl patches, for example) and the other involved non-opioid medications (a progression from ibuprofen to nortriptyline to tramadol, for example).

The medications were adjusted based on patient preferences and responses. Providers could switch patients to different drugs at the same level; change the dose or frequency of doses; add other drugs to manage side effects; and move patients up or down levels of intensity. They were also allowed to use any nonpharmacological pain therapies they liked.

The results were unexpected:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It doesn’t matter what works better in theory; it only matters what works better in practice.[/pullquote]

The study followed 240 patients for 12 months. Pain-related function, or how much pain affected their activity, was no different between the two groups. Pain intensity was actually better in the non-opioid group, and adverse symptoms were lower in that group as well.

How can that be? We know that opioids are “stronger” than non-opioids in theory; shouldn’t they perform better is practice?

Not necessarily because there is a difference between explanatory trials and pragmatic trials.

…[M]ost studies, even the gold standard of randomized controlled trials, focus squarely on causality. They are set up to see if a treatment will work in optimal conditions, what scientists call efficacy. They’re “explanatory.”

Efficacy is important. But what we also need are studies that test if a treatment will work in the real world — if they have effectiveness.

These … are called pragmatic trials …

It’s the difference between theory and practice. In theory opioids provide superior pain relief; in practice other medications can actually be more effective and have the additional, major benefit of avoiding opioid addiction.

This does NOT mean that the explanatory studies that showed opioids aren’t stronger than non-opioids were wrong. In the perfect conditions of the explanatory studies, opioids are more effective. But in real world conditions, they have no additional benefit and dramatically increased harms.

The take away message is this: it doesn’t matter what works better in theory; it only matters what works better in practice.

What does this have to do with childbirth and breastfeeding? Quite a lot as it turns out.

There are many explanatory studies of childbirth that claim to show that unmedicated vaginal birth is superior to C-sections. Natural childbirth advocates, midwives in particular, have seized upon these studies to rationalize their preference for unmedicated vaginal birth as an ideal toward which providers and hospitals should aim. The Royal College of Midwives in the UK used such studies to justify their “Campaign for Normal Birth.” The RCM predicted that their campaign would reduce intervention rates, save lives and save money.

That’s not what has happened. Indeed, the results have been disastrous. Maternal and infant health has not improved; preventable infant and maternal deaths have climbed; maternity liability payments have exploded.

Why? Partly this reflects the fact that many of the explanatory studies don’t correct for confounding variables so their results don’t show what their authors claimed. But mostly it reflects the fact that although unmedicated vaginal birth — like opioids — may be better in theory; it’s NOT better in practice.

Similarly, there are quite a few explanatory studies of breastfeeding that claim to show that breastfeeding is superior to formula. Lactation professionals have seized on these studies to rationalize their preference for breastfeeding over formula feeding. The Baby Friendly Hospital Initiative (BFHI) is a campaign to promote breastfeeding. Lactation professionals predicted it would increase breastfeeding rates, save lives and save healthcare dollars.

That’s not what happened. While the BFHI has increased initial breastfeeding rates, the fall off after leaving the hospital is quite dramatic. With the exception of extremely premature infants, it hasn’t been shown to save ANY lives in industrialized countries and certainly hasn’t saved any healthcare dollars on term infants. In fact, literally tens of thousands of babies are readmitted to the hospital each year because of breastfeeding problems (primarily insufficient breastmilk) at a cost of hundreds of millions of dollars

Why? Partly this reflects the fact that many of the explanatory studies of breastfeeding don’t correct for confounding variables. But mostly it reflects the fact that while breastfeeding — like opioids — may be better in theory; it’s not better in practice. Indeed, for some babies exclusive breastfeeding leads to serious health problems, permanent brain injuries and even death.

Where do we go from here?

No doubt drug companies will try to discredit the results of pragmatic trials of opioids and continue to bombard doctors with explanatory trials that show that opioids are stronger. Hopefully, doctors will no longer be swayed by the explanatory trials alone and will demand data demonstrating how opioids perform against non-opioids in the real world.

Similarly, midwives and other natural childbirth advocates completely dismiss the fact that campaigns for normal birth have utterly failed to produce the predicted results. They haven’t met a midwifery scandal resulting in preventable infant and maternal deaths that they don’t lie about, deny, hide and ignore. They comfort themselves and each other with “research” by which they mean explanatory trials. The only question remaining for the rest of us is how many more babies and mothers have to be harmed and die before obstetricians, government officials and public health authorities insist that midwives prove their claims are true in practice, not just in theory.

Lactation professionals behave in exactly the same fashion as midwives and opioid manufacturers. They dismiss the fact that the BFHI and other efforts to promote breastfeeding have utterly failed to produce the predicted results. When confronted with data that the benefits of breastfeeding in industrialized countries are trivial, that no term babies lives have been saved and no healthcare dollars have been saved, they wave explanatory studies that demonstrate the theoretical benefits of breastfeeding. The only question remaining for the rest of us is how many more babies and mothers have to be harmed or even die before pediatricians, obstetricians, government officials and public health authorities insist that lactation professionals prove their claims are true in practice, not just in theory.

As Carroll notes:

Randomized controlled trials are great for certain things. They absolutely have their place in determining efficacy and causality. But sometimes pragmatic trials are better. If we want to see improvements in care in the real world, not just the lab, we may need to push for more of them.

That applies to opioids and it applies equally to efforts to promote unmedicated vaginal birth and breastfeeding.

On Saturday I came across this tweet by one of the authors of the award winning ProPublica series on maternal mortality, Lost Mothers.

Very excited to be speaking today at DONA International 2018 Summit to a group of women who have done so much to protect other women from becoming Lost Mothers: doulas.

What have doulas done to prevent maternal mortality? I could find no peer reviewed scientific evidence that doulas have done ANYTHING to reduce maternal mortality.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]How can doulas, who have fewer hours of training than some labors, prevent maternal deaths?[/pullquote]

But that hasn’t stopped the ugly effort of doulas to claim they can. And people are listening (although not applying any critical thinking). According to The New York Times:

Gov. Andrew M. Cuomo announced on Sunday a series of initiatives aimed at addressing a disturbingly high rate of maternal mortality among black women, who are four times more likely to die in childbirth than white women in New York State, according to a study released last year.

The plan includes a pilot program that will expand Medicaid coverage for doulas, birth coaches who provide women with physical and emotional support during pregnancy and childbirth.

Studies show the calming presence and supportive reinforcement of doulas can help increase birth outcomes and reduce birth complications for the mother and the baby…

We’re supposed to believe that doulas, who have fewer hours of training than some labors, can prevent maternal deaths?

I’m not exaggerating. Doula training involves only 16 hours of workshops. It is not unusual for the average first labor to last hours longer than that.

The leading causes of maternal mortality are cardiac disease, other chronic pre-existing disease and serious medical complications of pregnancy; how could doulas possibly prevent those? They can’t. It’s an especially puzzling claim when you consider that, as detailed in the Lost Mothers series, many women who die initially received false reassurance that the symptoms of their impending demise were merely variations of normal. Doctors’ chief complaint about doulas is that they offer women false reassurance in the face of high risk status and complications. So how are doulas, who are more likely to offer false reassurance, going to prevent doctors from offering false reassurance? They aren’t.

What’s this really about? Follow the money!

It’s yet another effort by “birth workers” to exploit tragedies to promote themselves. Doulas are desperate to have their high fees covered by insurance and Medicaid; they are expensive and most women can’t afford them. Insurance companies and Medicaid are unlikely to pay doulas to improve women’s birth experiences but they might be willing to pay to reduce deaths, so doulas pretend they can reduce deaths.

This cynical campaign comes from the Ina May Gaskin playbook. Gaskin is the grandmother of America’s homebirth midwives — a second class of midwife different from certified nurse midwives, who fail to meet international midwifery standards and are found no where else in the industrialized world. Gaskin came up with the “Safe Motherhood Quilt” as part of her campaign to receive insurance and Medicaid coverage for this second, inferior class of midwives.

Gaskin represented herself as shocked at the rate of maternal mortality. Yet as far as far as I can tell, homebirth midwives in general and Gaskin in particular have done NOTHING (no research, no education, no fund raising) to reduce the incidence of maternal mortality. They merely exploited the deaths to promote themselves.

Doulas are now doing the same.

But aren’t there studies that show doulas improve outcomes?

I couldn’t find a single peer review scientific study that shows that doulas reduced maternal mortality. There are studies that show that doulas can decrease intervention rates, but that’s a process, not an outcome. Moreover, most studies of doulas are riddled with confounding variables; even when doulas are offered for free, the women who choose doulas differ in important ways from women who don’t choose them and those differences are likely to impact outcomes.

What about the work of midwife Jennie Joseph showing that support improves outcomes?

Jennie Joseph is a British-trained midwife, a women’s health advocate, the founder and executive director of Commonsense Childbirth Inc. and the creator of The JJ Way®. She moved to the United States in 1989 and began a journey that has culminated in the formation of an innovative maternal child healthcare system, markedly improving birth outcomes for women in Central Florida.

What’s the JJ Way?

The key components in our health care delivery are: prenatal bonding through respect, support, education, encouragement and empowerment.

But there’s no evidence that the JJ Way has improved health outcomes for anyone. It’s never been the subject of peer reviewed scientific research. So why does anyone think it works? Because a paid “report” claims it does.

The “report” concludes:

Women who received maternal care The JJ Way® had lower preterm birth rates than women in Orange County and the State of Florida…

Women who received maternal care the JJ Way® had significantly better low birth weight rate percentages than women in Orange County and the State of Florida…

This evaluation of The JJ Way® model of prenatal care showed elimination of health disparities in preterm birth outcomes and reductions in low birth weight babies in at-risk populations.

The report, produced by a sociologist and a mental health counselor, shows nothing of the kind. Why not? Because the authors failed to correct for confounding variables other than race. The women who participated in the program were a self-selected group. As such, they are likely to differ from the average women in the county and the state on demographics like income, pre-existing health conditions, substance abuse, smoking status and a variety of other characteristics.

Unless and until Joseph corrects for those confounding variables, she isn’t entitled to make any claims about her program.

The bottom line is that there is very little evidence that support improves outcomes as opposed to merely reducing interventions. And there’s no evidence that support prevents maternal deaths.

Of course, there’s nothing wrong with doulas; they can be very helpful to women. But there’s something very wrong with them exploiting maternal deaths to promote themselves.

There’s a tremendous overlap between natural childbirth advocates and lactivists. That leads to the central conundrum of natural parenting: IS a healthy baby all that matters or ISN’T it?

Natural childbirth advocates believe they know the answer. According to Milli Hill, writing in 2014, a healthy baby is NOT all that matters:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Why is the woman who chooses high risk homebirth lauded while the woman who chooses formula feeding denigrated?[/pullquote]

Women matter too. When we tell women that a healthy baby is all that matters we often silence them. We say, or at least we very strongly imply, that their feelings do not matter, and that even though the birth may have left them feeling hurt, shocked or even violated, they should not complain because their baby is healthy and this is the only important thing…

In other words, women’s experience of birth is critical to their health.

Too often women who say they care about the details of their baby’s birth day are accused of wanting an ‘experience’, as if it is selfish to care about how their baby is born, how they feel or how they are treated.

Notably Hill doesn’t question the validity of women’s desires. It is enough for a woman to want a birth experience that differs from the hospital routine in order for her to be entitled to it.

Hill, like most natural childbirth advocates, is passionately committed to the principle that a healthy baby ISN’t all that matters … right up to the moment of birth. After that, Hill is equally passionately committed to principle that when it comes to infant feeding, a healthy baby IS the only thing that matters.

Wait, what?

Shouldn’t Hill’s claims about birth apply equally to breastfeeding? Doesn’t she believe that when we tell women that when it comes to infant feeding a healthy baby is all that matters we often silence them? How can we justify saying, or at least very strongly implying, that their feelings do not matter, and that even though breastfeeding may have them feeling hurt, shocked or even violated, they should not complain because breastfeeding will guarantee their baby is healthy and that is the only important thing?

How does Hill rationalize this hypocrisy? By questioning the validity of women’s desires:

But surely, breast or bottle, it’s all down to personal choice.

Every parent should have the freedom to decide how they feed their baby, and nobody should be judged for the path they take.

Right?

Except, that would discount the persuasive power of marketing.

In other words, the exact same women who wouldn’t and shouldn’t be pressured to knuckle under to the “obstetric industry” with its promotion of technological birth are supposedly dupes for the formula industry.

How ironic is this? Let me count the ways:

It’s a violation of women’s autonomy. A woman’s right to control her own body is not expelled with the placenta. If a woman has the right to refuse to let anyone put fingers in her vagina to measure cervical dilatation, she ought to have the exact same right to refuse to let a lactation consultant grab her breast and shove her nipple into an infant’s mouth.

It’s disrespectful of women. While Hill and her natural childbirth colleagues have no trouble believing that women who make alternate choices for childbirth are “educated” and empowered, Hill and her lactivist colleagues cannot imagine that women who make an alternate choice to breastfeeding are equally educated and empowered.

It is utterly inconsistent. Although a healthy baby is supposedly NOT the only thing that matters when it comes to childbirth, a healthy baby is purportedly the ONLY thing that matters when it comes to infant feeding.

It seems impossible to reconcile these diametrically opposed views of women’s autonomy, ability to make informed decisions, and importance given to a baby’s health.

But not if you look at it from a different angle, an angle that takes the views of natural parenting professionals as central. Their view is in that any conflict between what is good for women and what is good for them, their needs and desires ought to take precedence.

For Milli Hill and her colleagues who profit from promoting natural childbirth, encouraging women to buy their books, products and services is always an unalloyed good. That means that women who choose their experience over the health of the baby must be supported in every way.

For Milli Hill and her colleagues who profit from promoting breastfeeding, encouraging women to buy their books, products and services is always an unalloyed good. That requires that women who choose their experience over the purported health of the baby must be excoriated in every way.

The woman who chooses to ignore medical advice and have a high risk homebirth is to be lauded but the woman who chooses to ignore medical advice and formula-feed must be decried as gullible, uneducated and selfish.

What matters is not the health of the baby but the financial health of Milli Hill and her colleagues.

When you look at it that way, it all makes perfect sense.

I don’t know Dr. Joan Y. Meek, Chair of the Section on Breastfeeding of the American Academy of Pediatrics, but I do know ridiculous hyperbole when I see it. Sadly, Dr. Meek is aggressively promoting it.

Meek wrote a piece, Breastfeeding has been the best public health policy throughout history, which has been republished in a variety of places. Too bad it’s complete and utter nonsense.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Nonsense in the service of righteous ends is still nonsense.[/pullquote]

Dr. Meek claims:

As a pediatrician and a nutritionist, I have provided direct patient care to breastfeeding mothers and children and also advocated for breastfeeding policies and practices. The scientific research in support of breastfeeding is overwhelmingly clear, and most mothers in the U.S. have heard that message and learned from it. Marketing and sales of infant formula have surged in developing countries, however. That’s created a dilemma for the U.S., which has not wanted to restrict the US$70 billion infant formula business.

This comes at another price. Lack of breastfeeding worldwide is blamed for 800,000 childhood deaths a year.

No, breastfeeding does NOT save 800,000 lives a year. That’s based on a mathematical model that did not correct for confounding variables and assumed, but never proved, causation. Indeed, until recently, lactivists had been unable to find any supporting evidence for that claim. They could not show that breastfeeding rates are correlated in any way to infant mortality. In fact, countries with the lowest breastfeeding rates have the lowest mortality rates and countries with the highest mortality rates have nearly 100% breastfeeding rates.

The best evidence on lives saved by breastfeeding, published only recently, is Mortality from Nestlé’s Marketing of Infant Formula in Low and Middle-Income Countries by Gertler et al.

Contrary to the claims of lactivists like Dr. Meek:

The introduction of infant formula shows no statistically significant average impact on infant mortality for the population as a whole.

That’s because formula is not harmful to babies; contaminated water is harmful. How harmful?

[An analysis] yields an estimate of 65,676 infant deaths with a 95% confidence interval of [24,868, 106,485], lower than earlier estimates of one million or more, but unquestionably a substantial loss of human life.

That was 1981. How about now?

According to Gertler:

…[T]he annual death toll has dropped to about 25,000, driven by improved access to clean water in the Southern Hemisphere.

That’s just 3% of the figure claimed by Meek.

So breastfeeding is hardly the best public health policy in history; it doesn’t rate a place anywhere in the top public health achievements of all time.

Why?

Because a great public health policy saves millions or even hundreds of millions of lives. In contrast, with the exception of extremely premature infants*, breastfeeding hasn’t yet been shown to save many lives at all.

To understand what I mean, lets look at some of the real greatest public health achievements.

1. Clean water

2. Sewers and sanitation

3. Antisepsis

4. Blood transfusions

5. Antibiotics

6. Vaccination

7. Anesthesia

8. Tobacco control

9. Modern obstetrics

10. Neonatology

Each of these has saved and continues to save many millions of lives every year. Breastfeeding doesn’t come anywhere close. Moreover, the purported lifesaving effect of breastfeeding would be entirely abolished if all women had access to clean water with which to prepare formula.

Why did Dr. Meek make her ridiculous claim? Sadly, like most lactation professionals, she ignores the facts about breastfeeding in favor of the fantasy.

Meek writes:

The benefits of breastfeeding for children and mothers are irrefutable. Initiation of skin-to-skin contact immediately after delivery, with early onset of breastfeeding within the first hour of life, supports newborn stability and provides protective immunoglobulins, especially secretory IgA, and other immune protective factors. Human milk provides human milk oligosaccharides, facilitating the colonization of the intestinal tract with probiotics and establishing a microbiome that protects against pathogenic bacteria.

In contrast, formula-fed infants face higher rates of gastrointestinal diseases, respiratory infections and a higher likelihood of sudden infant death syndrome. Longer term, they have a higher risk of obesity, type 2 diabetes, asthma and certain childhood cancers when compared to breastfed cohorts.

Far from being irrefutable, most of these purported benefits have already been refuted.

• The protective immunoglobulins exist, but they only prevent colds and diarrheal illnesses.
• Claims about the microbiome are mere speculation.
• While breastfeeding reduces the risk of SIDS, pacifier use reduces it by a greater amount.
• Claims about obesity, diabetes, asthma and childhood cancers have been thoroughly debunked.

The idea that breastfeeding has been the greatest public health policy throughout history is sheer, unadulterated nonsense. I’ve no doubt that Dr. Meek is making that claim for what she perceives to be anticorporatist, righteous ends — counteracting the marketing efforts of formula companies. But nonsense in the service of righteous ends is still nonsense.

Who am I to criticize the claims of Dr. Meek? I’m a physician who is very familiar with the breastfeeding literature and I am more than willing to put my criticism to the test. I’d be happy to debate Dr. Meek, in print or in person, on these very issues.

I doubt my challenge will be accepted. Professional lactivists never put themselves in positions where those who disagree could challenge them. Though they choose fantasy over facts, they are aware that inconvenient facts about the limitations and risks of breastfeeding exist and they are afraid to face them.

Who knows? Maybe Dr. Meek, unlike other professional breastfeeding advocates, has the courage of her convictions. I’ll be waiting to find out.

 

*Breastmilk reduces the risk of necrotizing enterocolitis, a potentially deadly complication of extreme prematurity.

Breastfeeding or formula feeding?

It’s a choice that provokes strong feelings, particularly among those who identify themselves as breastfeeding professionals. It often seems that there is a huge gulf between organizations like La Leche League, whose avowed goal is to promote breastfeeding and Fed Is Best, whose avowed goal is to promote safe infant feeding whether that it breastmilk or formula.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Our goal: a society where any woman COULD breastfeed; but no woman feels she SHOULD breastfeed and no lactivist insists she WOULD breastfeed if only she knew better.[/pullquote]

I believe that the gulf can be understood by considering just three small words: “could,” “should” and “would.”

COULD

We need to create a society in which all women COULD breastfeed if that is their choice.

Despite the myriad disagreements between lactivists and feeding safety advocates, there’s no disagreement on this point. Although lactivists often claim that anyone who disagrees with them “hates” breastfeeding, there’s no evidence that this is the case. In more than two decades of writing about mothering issues, I’ve never come across a single individual who feels that breastfeeding itself is undesirable or substandard.

When we say we want a society where all women COULD breastfeed if they wish, most of us mean:

• Women should receive any medical and social support they need to successfully breastfeed
• Hospitals should supply medical professionals for breastfeeding guidance
• Women should have access to sufficient paid maternity leave to establish breastfeeding
• Women who return to work should have access to private pumping spaces and time to pump
• Breastfeeding in public should be welcomed everywhere

Sadly, that’s where the agreement ends.

SHOULD

Breastfeeding advocates believe that we need to create a society in which all women SHOULD exclusively breastfeed, barring rare health issues.

In the view of most lactation professionals, the benefits of breastfeeding are so obvious, so strongly supported by science and so profound that women must be prevented from choosing anything other than breastfeeding.

They reject any empirical claims that the benefits of breastfeeding in industrialized countries are actually trivial, that exclusive breastfeeding has significant safety risks for babies because of the high incidence of insufficient breastmilk, and that it places significant burdens — physical and psychological — on mothers.

But rejecting those claims doesn’t change the fact that they are true. Indeed, the massive popularity of the Fed Is Best movement reflects the experiences of literally hundreds of thousands of women who support it. Those women know that the incidence of insufficient breastmilk is high because they’ve personally experienced it. They know that aggressive promotion of exclusive breastfeeding has significant safety risks for babies because their babies have been hospitalized, suffered brain injuries and even died because of dehydration, low blood sugar or severe jaundice. They know that breastfeeding places significant burdens on women because they’ve struggled with mastitis, pain, exhaustion, difficulty combining breastfeeding and work, as well as the profound shame and guilt of not being able to exclusively breastfeed.

Infant feeding safety advocates, myself included, reject the notion that all women should breastfeed because we recognize that breast is NOT always best for every mother and every baby. Furthermore, we are feminists who believe that women have the right to control their own bodies; to use them in ways that they wish and they must never be forced to use them in ways that ignore their own needs. We reject claims of biological essentialism — that the true fulfillment of women’s purposes lies in reproduction and nurturing of children. We reject the notion that biology is determinative. Just because women are “designed” for penetrative intercourse does not mean that it is wrong for women to be gay or celibate; just because women are “designed” to breastfeed doesn’t mean that it is wrong to formula feed or combination feed.

WOULD

When faced with feminist arguments about the right to formula feed, breastfeeding advocates respond that all women WOULD breastfeed if only they were properly educated and not subject to the marketing efforts of formula companies.

There’s no scientific evidence to support that claim. The message that breastmilk is best is everywhere, even on formula itself. It is deeply disingenuous, not to mention misogynistic, to claim that women are too stupid to understand it and are in desperate need of greater education about the benefits of breastfeeding. It also implies that women are so gullible that they fail to recognize and are incapable of resisting marketing messages about formula. It denigrates women who choose formula by implying that their choice isn’t free and they have have been manipulated into it.

The existing scientific evidence shows the opposite: that women are well aware that breastfeeding has benefits and is considered best, that women resent being hectored, that language on the “risks” of formula feeding makes them angry, and that they are shamed and traumatized by the intense pressure to breastfeed.

In summary then, the differences between breastfeeding advocates and Fed Is Best advocates is not about “could.” All of us support a society where every woman who wants to breastfeed COULD breastfeed.

The disagreement resides in the words “should” and “would.”

Where does that leave us?

Breastfeeding advocates ought to stop whining that anyone who disagrees with them “hates” breastfeeding or is uneducated or gullible. They ought to stop promoting public breastfeeding as an antidote to formula feeding and recognize that feeding safety advocates don’t oppose public breastfeeding; social conservatives do.

Our goal ought to be creating a society where any woman who wants to breastfeed COULD breastfeed; but no woman feels that she SHOULD breastfeed and no lactivist insists that she WOULD breastfeed if only she knew better.

Breastfeeding professionals are sure that breastfed infants are healthier than those who are formula fed.

There’s just one problem; they can’t find evidence to support that belief.

Countries with the lowest breastfeeding rates have the LOWEST infant mortality and countries with the highest infant mortality have the highest breastfeeding rates. Most of the claimed health benefits of breastfeeding have been debunked by studies that correct for the higher socio-economic status of women in industrialized countries who breastfeed. And although breastmilk can save the lives of extremely premature infants who face the deadly risk of necrotizing enterocolitis, breastfeeding professionals can’t point to the lives of any term babies who have been saved.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Calibrate infant growth charts to keep infants out of the hospital, well hydrated and not suffering brain injuries and deaths.[/pullquote]

To the horror of breastfeeding professionals, the scientific evidence shows that formula fed infants are equally healthy to breastfed infants.

What to do? Change the definition of healthy by altering infant growth charts!

That’s just what breastfeeding professionals have done and it’s working … sort of.

The headline from the BBC is typical, Too many babies overfed, experts fear.

It’s time to tackle over-eating from birth to make sure children get the best start in life, according to Public Health England.

It comes as government advisers publish new guidance – the first in more than 20 years – on feeding babies.

That report suggests three-quarters of UK babies and toddlers may be eating more calories than they should.
The same proportion weighed more than the ideal weight for their age, when plotted on growth charts.

The data comes from the Infant Feeding Survey and the Diet and Nutrition Survey of Infants and Young Children carried out in 2010 and 2011.

It’s long been known that breastfed babies and formula fed babies grow differently.

According to the CDC:

The WHO growth charts establish the growth of the breastfed infant as the norm for growth. Healthy breastfed infants typically put on weight more slowly than formula fed infants in the first year of life. Formula fed infants gain weight more rapidly after about 3 months of age. Differences in weight patterns continue even after complementary foods are introduced.

Previous standards evaluated growth based predominantly on formula fed infants since most infants were formula fed at the time they were developed. Many breastfed infants were diagnosed as underweight using these charts. Breastfeeding advocates claimed that it was wrong to evaluate breastfed infants using formula fed infants as the standard.

They had a point, but it’s not clear that it was a valid one. It’s based on the assumption that every breastfed infant is fully fed when the reality is that breastfeeding has a significant failure rate and some breastfed babies are actually underfed. Far fewer babies receiving formula are underfed since they can eat until satiety instead of merely until the milk runs out.

The WHO charts purportedly show “how infants and children should grow rather than simply how they do grow.” But they don’t measure how infants “should” grow, they measure how breastfed infants, including underfed infants, grow. It’s a classic example of the naturalistic fallacy: if something is a certain way in nature, that’s how it ought to be.

This sleight of hand is only sort of working. Sure, it makes for great propaganda but it doesn’t change the fact that breastfed infants are suffering alarming rates of health problems due to insufficient breastmilk.

Breastfed infants are readmitted to the hospital at double the rate of formula fed infants. They are readmitted with hypernatremic dehydration, severe jaundice and hypoglycemia. In the US that translates to literally tens of thousands of hospital admissions each year at the cost of hundreds of millions of dollars. Brain injuries due to insufficient breastmilk are rising and infants are dying. Additional hundreds of millions of dollars of liability payments are being made.

In other words, redefining underfeeding as normal doesn’t change the fact that many breastfed babies are suffering gnawing hunger, dehydration, brain injuries and deaths.

I have a better idea:

Calibrate infant growth charts to keep infants out of the hospital, well hydrated and not suffering brain injuries and deaths.

If we don’t, we will continue to sacrifice the health of tens of thousands of infants each year to breastfeeding professionals’ increasingly desperate efforts to make breast SEEM best.

If gynecologists had a nickel for every time a teenage girl told them some version of the following, they’d be billionaires:

My boyfriend said I couldn’t get pregnant if we had sex standing up…
My boyfriend said I couldn’t get pregnant if I hadn’t had my first period…
My boyfriend said I couldn’t get pregnant if we did it during a full moon…

Most adult women recognizes such manipulation for what it is: lies told to convince women to cede control of ther bodies to young men. The young men may even believe what they say, but that doesn’t change the fact that their goal is to satisfying their own needs regardless of the harm that may come to the young women.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Teenage boys lie to young women so they’ll have sex with them. Natural childbirth and breastfeeding advocates lie to women so they’ll hire them and copy their choices.[/pullquote]

Such lies can be devastating, resulting in unintended pregnancy, sexually transmitted diseases and feelings of betrayal.

Sadly natural childbirth and breastfeeding advocates tell lies to women for similar reasons: to pressure them to cede control of their bodies. Natural childbirth and breastfeeding advocates may even believe what they say, but that doesn’t change the fact that their goal is to satisfy their own needs (for having their choices mirrored back to them or for increased employment as midwives, doulas or lactation consultants) regardless of the harm that may come to new mothers or their babies.

Such lies can also be devastating, resulting in extreme pain, traumatic births, incontinence, sexual dysfunction in the case of childbirth or in the case of breastfeeding maternal pain, exhaustion and shame in addition to newborn starvation, brain injury or death.

What follows is a list of the top ten lies used to manipulate expectant and new mothers:

1. Authentic women have no pain in labor. This is the foundational lie of natural childbirth advocacy, fabricated by Grantly Dick-Read, the father of natural childbirth. He claimed with no evidence whatsoever that primitive (i.e. black) women had painless childbirths because they recognized childbearing as their primary responsibility.

Dick-Read triggered a competition among privileged white women proving their authentic womanhood by denying the pain of labor and refusing pain relief. That competition continues to this day with women going so far as to claim they had not merely painless births, but orgasmic births. In falling for this lie, women have ceded control over their pain so that natural childbirth professionals can control their births.

2. C-sections are harmful. There was a time when C-sections WERE harmful and even deadly. Because of the dangers, just about any physical manipulation of babies and women — difficult mid-forceps rotations, massive vaginal and perineal tears — were justified in order to avoid the danger.

With the introduction of spinal/epidural anesthesia, C-sections have become remarkably safe. Nonetheless natural childbirth continue to rail against the dangers and completely ignore the risks of vaginal birth. Why? To satisfy their desperate need to have their own choices mirrored back to them, as well as to increase the employment opportunities for midwives and doulas.

3. Vaginal birth has an easier recovery than C-section. That depends entirely on what came before the birth. A vaginal delivery following 40 hours of labor including 5 hours of pushing is going to have a much longer recovery than an elective repeat C-section undertaken before labor begins.

4. There are no long term side effects to vaginal birth. To hear natural childbirth advocates tell it, the most important long term complication of birth is a future placenta accreta from a previous C-section. Placenta accreta is indeed dangerous, but the longterm complications of vaginal birth are far more common and debilitating. The risk of urinary incontinence from vaginal birth is 10,000% higher than the risk of subsequent accreta. No matter. Natural childbirth advocates routinely lie to women by omission, failing to disclose the risks of urinary incontinence, pelvic organ prolapse and sexual dysfunction.

5. Doulas are good for women. Doulas are undoubtedly good for doulas, but not necessarily good for mothers. Indeed, the metrics often used to evaluate doulas are epidural and C-section rates. Doulas are good at avoiding epidurals and C-sections, but epidurals relieve suffering and C-sections are often better for babies or mothers. A vaginal birth is not a victory when it results in a brain injured baby or decades of maternal urinary incontinence.

6. Insufficient breastmilk is rare. Breastfeeding advocacy is based in large measure on the Panglossian paradigm. The Panglossian paradigm asserts that everything that exists in nature today is the product of intense natural selection and represents the perfect solution to a particular evolutionary problem. Therefore, breastfeeding must be perfect.

But the scientific evidence shows that breastfeeding is not perfect. Lactation professionals routinely lie about the fact that up to 15% of first time mothers cannot produce enough breastmilk to fully nourish a baby especially in the early days. Instead of admitting this and offering formula supplementation, lactation consultants let babies suffer gnawing hunger and risk brain injury and death.

7. A newborn’s stomach is tiny. This is simply a bald-faced lie.

Lactation consultants tell new mothers that the average size of a newborn baby’s stomach is only a teaspoon (5 cc). That’s supposed to ease their minds when their newborns are screaming in hunger and they can tell that they are producing very little colostrum or milk. But the average size of the newborn stomach is NOT 5-7 cc but closer to 20 cc, rising dramatically over the first first days. If a baby seems hungry; she probably is hungry.

8. If breastfeeding hurts your baby needs surgery. Since breastfeeding is supposed to be perfect, problems must be ascribed to babies. The rate of diagnosis of tongue-tie and the surgery to sever it has exploded. Yet scientific studies show that the rate of tongue-tie is as low as it ever was and that surgery to “repair” it is largely ineffective in solving breastfeeding problems. Literally thousands of babies are undergoing painful, unnecessary surgery each year to maintain the illusion that breastfeeding is perfect.

9. Breastfeeding saves lives. There’s no evidence that breastfeeding saves lives in countries with easy access to clean water. The one exception is the case of extremely premature babies, where breastmilk reduces the deadly risk of necrotizing enterocolitis. While lactation professionals tout mathematical models showing that breastfeeding saves lives in theory, they are unable to identify ANY term babies whose lives have been saved in practice.

10. Breastfeeding promotes bonding. This is the cruelest lie of them all, intimating that babies who breastfeed are more bonded to their mothers than those who formula feed. There is not and there has never been any evidence to support this vicious falsehood. It is merely a particularly ugly attempt at pressuring women.

The bottom line is this: many people lie to women in order to control their bodies. Teenage boys lie to young women so they’ll have sex with them. Natural childbirth and breastfeeding advocates lie to women so they’ll hire them and copy them. But lying to women to control them — regardless of motivation — is always wrong.

Last week I wrote about conventional wisdom and used the example of stomach ulcers.

When I started medical school, the conventional wisdom was that stomach ulcers were caused by excess acid. The conventional wisdom was loud, pervasive and impossible to ignore. Whole careers in gastroenterology had been staked on maintaining its veracity. When that veracity was challenged, the challengers were silenced.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]You can almost hear their eyes roll when a woman tells of her anguish at being unable to produce enough breastmilk.[/pullquote]

At about the time I graduated from medical school researchers Robin Warren and Barry Marshall discovered H. pylori, the bacteria that actually causes gastric ulcers. Because of cognitive bias and the logical fallacy of argument from authority (all the prominent medical associations were in agreement that acid caused ulcers!), he was ignored.

But then:

To defend his thesis, in 1984 Marshall intentionally drank cultured H pylori and developed gastric symptoms, which were relieved with antibiotics. Another health professional who was similarly frustrated by the rejection of the theory of an association between H pylori and gastritis leading to peptic ulcer disease also consumed the putative agent. Multiple gastric biopsies before and after ingestion nicely demonstrated the resulting disease; however, Marshall’s colleague was less fortunate because antibiotics were unsuccessful in eradicating his disease, and he had debilitating symptoms for 3 years.

To my knowlege, although there was fierce professional disagreement during those years, those favoring the original acid theory never accused the researchers who claimed that bacteria caused ulcers of nefarious motives, shilling on behalf of a corporate entity, welcoming patients’ deaths or hatred of stomach acid.

Sadly, the same cannot be said about breastfeeding. Professional breastfeeding advocates have created a culture of contempt for anyone who dares challenge the conventional wisdom.

For example, on Saturday The New York Times published yet another piece about breastfeeding, Breast-Feeding or Formula? For Americans, It’s Complicated. Author Christina Caron noted:

But now a new movement called Fed is Best has arisen because of the pressure placed on women to exclusively breast-feed, sometimes to the detriment of their infants. The movement seeks to educate families about all of the safe feeding options available to them, and the complications that can arise when exclusively breast-fed newborns don’t receive enough breast milk.

In response, Lucy Martinez Sullivan, a lobbyist for the lactivist organization 1000 Days, reached out to the author with this Tweet:

Ask who is behind the “Fed is Best” movement. Investigate. Do your homework @cdcaron. Ask who stands to benefit claiming women are harmed by the “pressure to breastfeed”

Followed by this one:

@cdcaron The @nytimes should ask if Fed is Best is a fake grassroots movement / industry front group – pushing disinformation about the supposed dangers of #breastfeeding.

Does Martinez Sullivan have any evidence that Fed Is Best Founders Christie del Castillo-Hegyi, MD and Jody Seagrave-Daly, RN IBCLC are anything other than concerned health professionals who make no money from teaching others to recognize the signs of insufficient breastmilk? Of course not.

It’s easy to obtain tax records from non-profit foundations. The tax records from Fed Is Best reveal that both Christie and Jody receive $0 compensation. In contrast, Martinez Sullivan makes $168,968/yr to promote breastfeeding.

So why did Martinez Sullivan feel free to make such outrageous, unsubstantiated claims? I suspect it is because breastfeeding advocacy has created a culture of contempt for anyone who challenges their beliefs and claims. Under the influence of cognitive bias, which allows them to ignore the scientific evidence that breastfeeding has significant risks, the fallacy of argument from authority (the WHO, the AAP and every other medical organization promote breastfeeding as lifesaving!) and white hat bias (Nestlé!), they freely express their contempt for Fed Is Best.

That culture of contempt begins with the way that lactation professionals (and lay lactivists) view women who don’t breastfeed. They portray them as running the gamut from lazy (too selfish and self-absorbed!) through stupid (they are duped by formula companies!) up to the supposed moral high ground of helpless (they didn’t get enough support!). Lactation professionals view women who don’t breastfeed with such contempt that it never even occurs to them that women may have personal reasons for not breastfeeding or may have made an informed decision not to do so.

The result of their contempt is that babies become breastfeeding casualties. The single biggest risk of breastfeeding is dehydration and related complications from insufficient breastmilk. Up to 15% of first time mothers will not produce enough breastmilk to fully nourish a baby, especially in the early days after birth. Professional lactivists deliberately lie, insisting that insufficient breastmilk is vanishingly rare, despite the fact that the latest scientific evidence indicates that there are literally tens of thousands of newborn hospital readmissions each year for this complication. You can almost hear their eyes roll when a woman tells of her anguish at being unable to produce enough breastmilk. They hold women who don’t breastfeed in such profound contempt that they laugh at their distress and accuse them of faking it to selfishly avoid breastfeeding.

To say that lactation professionals lack insight into their own behavior is a profound understatement. Backpedaling frantically after being called out for her vicious accusations, Martinez Sullivan responded:

No mother should ever be shamed or stigmatized for how she feeds her child. Aside from being hurtful, this is “mommy war” nonsense that plays into the hands of the formula company giants, who pretty much invented the infant feeding mommy wars.

But implying that women who can’t or don’t want to breastfeed are dupes “in the hands of formula company giants” IS shaming. It’s yet another expression of contempt.

Breastfeeding professionals’ contempt toward other professionals who point out the risks of breastfeeding knows no bounds. Whether referring to Christie and Jody, myself, Courtney Jung or Joan Wolf, they don’t hesitate to imply that we are on the payroll of some nefarious organization or simply unconcerned with the health and wellbeing of babies. Those who earn their money promoting breastfeeding can’t imagine that feeding safety advocates might love babies more than they love money.

As I noted above, doctors favoring the original acid theory of stomach ulcers never accused researchers who claimed that bacteria caused ulcers of nefarious motives, shilling on behalf of a corporate entity, welcoming patients deaths or a hatred of stomach acid. In contrast, those who insist that breastfeeding is both lifesaving and almost perfect routinely accuse anyone who challenges them of shilling on behalf of formula companies, welcoming infant deaths and (my personal favorite!) hating breastfeeding.

Here’s a quote that breastfeeding professionals ought to keep in mind:

Science: If you don’t make mistakes, you’re doing it wrong. If you don’t correct those mistakes, you’re doing it really wrong. If can’t accept that you’re mistaken, you’re not doing it at all.

It is understandable that breastfeeding professionals have made mistakes in claiming that breastfeeding is perfect and complications are rare. But if they don’t correct those mistakes, they’re doing science wrong.

And if they can’t accept that they are mistaken — and treat everyone who disagrees with contempt — they aren’t doing science at all.